Tag Archives: patient abuse

If you do not know exactly what happened, please read parts 1 and 2 previous to this post.

I will now post the Nursing Board result of the investigation, complete with the two nurses now in agreement and colluding to maintain that I attempted to stab them! NOTHING of this is in the chart or the accounts from any previous investigation, and I have the papers to prove it. But suddenly they grew new memories of what happened? Bullshit,. they lied to save their jobs, and it is clear that they got together to agree on a story, since it never even came close to happening as their now consistent with each other lies maintain.

But review the records and tell me what YOU see….Because to me it is OBVIOUS that they got away with abuse and soul murder.

I admit that even though it was early in the morning on November 18, 2015 on Unit D at the Vermont Psychiatric Care Hospital’s Unit D, I was slamming doors. The noise was very loud. Yet never before had this triggered anything from the unbelievably patient and forbearing staff on Unit D, except perhaps some bemused bewilderment at what set me off. After all, with only 3 patients on the unit at any time and the other two either still awake, or highly medicated and dead to the world, it usually did not matter to anyone if I raised a ruckus. But this time, because Annette Brennan was the nurse on duty, it mattered a great deal more than it should have.

Instead of letting me slam my door a few times and cool off, as I had so often before, Nurse Brennan came barreling through the doorway and into my bathroom, where I had been sleeping on a mattress since shortly after my admission, two weeks before. I backed away. Brennan pushed up closer, yelling at me, “You will not slam any more doors tonight, do you understand?!”

To explain what preceded this, you should know a little of the “backstory.” I had gone to the med window about a half hour earlier, asking for an extra Ativan for “anxiety”. But really I needed it because I had been unable to speak since Nov 15. On November 19, people were coming to evaluate me from Meadowview Recovery Residence in Brattleboro, and I needed to be able to have a voice to speak with them.

Now, you should be aware that for many years catatonia and long episodes of mutism have been a problem for me. In 2003, a Connecticut doctor discovered that Ativan by
IV was effective for my catatonia. When mutism was the bigger problem, my outpatient doctor at the time decided to try Ativan orally, seeing mutism as a feature of catatonia, and she used it with good result.

However, at VPCH the on-call doctor, Dr. Lasek, had not been told about my relapsing mutism, nor my need for Ativan. He only knew about my complaints of sleeplessness and anxiety. So when called around 1:30 AM he refused me a second tiny dose and ordered me to try to relax on my own and sleep for two hours, before he would order another.

This is what occasioned, at nearly 2:00 AM, my panicked outburst of door slamming. But the real trigger for what followed was that Nurse Brennan did something she should not have. My advance directive explicitly warns against it. She grabbed me by

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the wrists. Yes, feeling threatened by her being up in my face, I had thrown a notebook at the wall. But I had not thrown it at her, as Nurse Mansukhani who was watching all this, explicitly states in both the chart and her APS interview. Maybe having cornered me in the bathroom, Nurse Brennan saw my mute shaking my fists as threatening. Even so, she ought to have backed away. Just backed away not provoked trouble.

Instead, she approached closer and, here is the thing, she reached out and she grabbed both my wrists. Immediately, the other nurse, Jennifer Mansukhani, watching from the door, said to her, “We don’t go hands on here at VPCH.” I want to repeat this because it is vitally important, even though it was never mentioned in the chart. Nurse Mansukhani cautioned Annette Brennan, even as she grabbed me: “WE DON’T GO HANDS ON HERE AT VPCH.”

But no one, not Jennifer Mansukhani, not anyone, came to my aid. I pulled and I struggled to get loose from her grip but Nurse Brennan only held on tighter. So reflexively, and in terror, I bent my head to bite her fingers with my teeth, desperate to get her to release me. And the chart says as much when it reports, “Patient tried to bite staff times 3.” Well, of course I did not just up and bite staff for no reason. The reason, the only reason, I bit staff, that is, bit nurse Brennan, is because she had me by the wrists and restrained me, without just cause. And because being mute i could not simply tell her to let go!

Of course all hell broke loose. The nurse yelled for help and help arrived in seconds with staff now officially going “hands on” to stop me from biting and to restrain me completely .

As they bodily hoisted me off the floor, screaming but wordlessly, one man asked, “What now? Brennan answered promptly, “Bring her to seclusion!” and so following her directive, without trying any other intervention, they carried me there, even though there was a large armchair right in the empty day room they could have placed me in to calm down…

So there I was, in seclusion largely because Nurse Brennan had backed me into my own bathroom and grabbed my wrists in a moment of inappropriate anger, telling me I was not going to slam doors on her watch.

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After staff dashed from the seclusion room, I ran after them but they closed the door, locking me in alone. Dazed and sad, and frightened, I sat back down on the mattress, not moving, my back to the door. I heard them talking. Scarcely listening, I tried to calm myself and wondered how long they planned to keep me locked in that room. Then I heard someone say, “She has her glasses and watch. We have to take them away from her!” (So what? I thought. What is the problem?)

But they piled in again, all of them pushing on top of me at once, knocking me in the face and severely bruising my nose and breaking my eyeglasses in their zeal to take away my glasses and watch and my medical band. Then they proceeded to fondle my body, looking for pockets, of which I had none. All this time I was screaming, without verbalizing a word…and fighting them in protest at their violation of my person. They tried to dash out of the room and lock me alone inside again, but I followed them and escaped, wedging myself in-between their ranks. So someone said. “Back inside!” and we all moved as one, back in towards the mattress.

Instead of trying anything to calm me or disentangle themselves and leave again, or better yet trying to follow the instructions on my detailed Advanced Directive and the one plea I had made from the moment I arrived at VPCH, which was never to leave me alone in a seclusion room, imagine my dismay when I heard nurse Brennan shout, “Get the Bed!”

The bed? The restraints bed? For what? What had I done to deserve The Bed? All I had done was try to get out of their terrifying seclusion room, a seclusion room I never deserved to be dragged to in the first place!

But the bed was gotten and as they clamped restraints on my body, Ms Brennan was the person who held my head between her hands as she commanded me — I was howling in terror beyond words, without any words – “YOU WILL CALM DOWN RIGHT THIS MINUTE!” Again and again, gripping my face between her hands, she ordered me to calm down.

You should be aware that my advanced directive EXPLICITLY states and always has, and they were aware of this, that I have been deeply traumatized by the use of restraints and seclusion and that their use should be avoided at ALL costs.

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Holding me down as I screamed, they fastened an extra restraint, a fifth restraint, a thick plate of velcro across my chest so I could not sit up nor do more than bend my neck slightly, before I lost strength and had to put my head flat on the narrow gurney.

Then what I can only term “the goon squad” trooped out, with Annette Brennan and Dr Joseph Lasek leaving last, saying, and I want to emphasize this because of its sheer brutality: “You will tell us out loud when you are safe enough to be released, or you will remain in restraints.” Then they departed too.

Although two monitors were posted in the adjoining room, I could not see them because of the chest restraint, nor were they permitted to say a word to me. I screamed in despair and terror but it made no difference. Yes, I once heard Chelsea’s voice from somewhere, a sweet, female staff member who had remembered my Advance Directive. She took a risk and told me from her position across the other room, “Pam, try to take a deep breath, try to calm yourself, I am here, you are not alone…” I tried to be grateful, indeed I was grateful. But as soon as I heard that Chelsea was there for me, they replaced her with someone who was told in no uncertain terms not to speak to me again.

I remained very still and so was rewarded with an assessment at every fifteen-minute interval to see whether I was “safe enough” to be released from restraints. Time and again they said I was “non-responsive” or non-compliant because I could not answer them in spoken words. Nurse Brennan made a point of checking my restraints and touching my body, without asking permission. You can read this in the chart if you do not believe me. She expected me to accept her touching me, and not flinch or kick in reaction. But no one would frame Yes or No questions to allow me to communicate! Yes, I became increasingly frustrated and upset. I was not unwilling to answer their questions, I was simply unable to. And they would leave me in restraints, again and again, hour after hour, writing in their chart notes that because I “refused to speak” I would stay that way.

First one hour passed, then two, then three. Finally the nurse Jennifer Mansukhani, relented and allowed as how I might answer the “safety” questions with a shake or nod of my head.

Will you get up go back to the unit to and to your room and continue to behave safely if we let you out of restraints?” (I am writing these questions from memory so they won’t be exact, but you get the gist of them.)

Nod, nod, nod.

Ms. Mansukhani seemed pleased with my responses but also at a loss as to what to do with them. She paused. “Okay, Pam. I have to go back and confer with Nurse Brennan and the doctor.”

She left, turning her back, promising to be back shortly.

Instead, it took an hour, and when she did come back, she arrived with Nurse Brennan and a plan. “We have decided that we want to free up a hand so you can write a safety plan. Then if we approve it and if it is adequate we will see about taking you out of restraints.”

I frowned. Annette Brennan had in the meantime moved to the end of the gurney where my stocking feet were exposed. Her groin pushed against my toes and the soles of my feet. I felt an immediate revulsion, feeling molested by someone who knew I was vulnerable. Helpless to resist, I kicked out mightily. If I could have spoken in words I would have yelled too, but I could say nothing, only scream wordlessly and kick. This got her to swiftly move away. Someone else present suggested that she pass me at the head of the bed next time.

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But writing up a safety plan was just upping the ante. I shook my head emphatically. They trooped out, leaving me alone again, still in restraints at 5:00 o’clock in the morning.

My muscles and veins hurt because I had remained still for so many hours. Afraid I would develop a blood clot, I carefully circled each leg ten times, restraints clanking as I did so. Then I bent each knee a few inches up and down, up and down. Ditto with my arms, until I was satisfied that I had done enough and could relax into the absolute stillness required for an assessment. I later learned my self-administered range-of- motion exercises was described as “patient flailing in restraints.”

Jennifer returned around 6:30. Making motions of desperation, I offered to write a safety plan. But the night shift was leaving. “First shift will have to take you out of restraints. It is too late for us to do it now.”

When I heard this, I let out a despairing howl and suddenly urine poured into my clothing. That meant little to the third shift; they left doing nothing about it. Only when first shift came on and found me, soaked in urine, and still in five-point restraints at 7:00 am did they relent and give me both Ativan and my morning meds. Even so, I wasn’t actually released until 7:30 am.

A patient has the right to be free of unnecessary restraint, and to have the least restrictive environment possible. The fact is, I DID NOT POSE AN
IMMINENT THREAT OF HARM TO SELF OR OTHERS when this incident occurred. I only fought when assaulted by people restraining or secluding me!… I should never have been placed in restraints. Any possible danger – kicking when Annette’s groin pressed against my bare feet? or merely grimacing? — that I may have seemed to pose was wholly induced by the situation.

It is repeatedly on record that Annette Brennan, RN, with the doctor’s complicity ordered that I was not to be released from 5-point restraints until I spoke aloud, stated multiple times in multiple ways. This led to many instances of grotesque abuse, including when Nurse Brennan pushed her groin against my bare feet and then accused me of kicking her.

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Please understand what happened: I was immobilized in 5-point restraints, including a large chest restraint. She herself noted that I was lying quietly at the time. So why and how did Ms. Brennan’s groin make contact with my bare feet? I could not “lunge” at anyone, despite the notation later made in my chart. I could not even see Nurse Brennan unless she was right at my side. She pressed her groin against my feet while I was in a helpless and vulnerable state. So I protested by kicking out to the very extent that my restraints allowed. Her behavior violated every professional standard and code there is. It was indeed abuse of everything a nurse stands for.

Abuse was intrinsic to the situation that Brennan (with Dr. Joseph Lasek’s complicity) set up. I should have been released very quickly, except that the staff involved repeatedly refused to ask me their “safety questions” in a manner to which I could respond. Since they had decided I “refused to speak,” they would not permit me to communicate in any other fashion. They acknowledged this was deliberate both verbally and in writing. Several times, the chart says, I was lying quietly in 5-point restraints on the bed, but as I “refused to speak” I would not be released.

Even when Nurse Mansukhani relented enough to ask me the requisite “safety questions” in a yes/no fashion, I had not met their conditions for release so they left me there. This was punishment, and it was abuse, pure and simple.

Finally, I want to show you just one example of what these illegal conditions of release led to, the supposed violence I exhibited and their claims that “patient still needs restraints.” The chart states that they offered me “patient’s own blanket,” when they discovered that I was cold. My response is described as “violent.” What they don’t say is that this was the hospital’s extremely heavy weighted blanket, filled with shot pellets. When Nurse Mansukhani had a male tech bring this and try to drop it on top of me, a patient shackled in 5-point restraints, I was terrified for my life and I responded from that fear: I could not understand why anyone would do such a thing unless they were trying to suffocate me.

(Why in god’s name didn’t they just release me from restraints at that point? I was obviously not trying to harm anyone or myself. I was shivering from the cold that was all…Why? Because they were intent on punishment, not in fact on safety.)

But you see how interpretations written in my chart became inaccurate in the extreme? Because Nurse Brennan insisted on my speaking aloud rather than finding some way for me to communicate, she deliberately rejected any attempt to understand what was going on.

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Nevertheless, the fact remains that whether I refused to speak, as she claimed, or whether I could not speak, which was reality, it does not matter. I had the right not to be restrained as punishment or for coercion. I also have always had the right not to speak and to communicate however I so choose, whether VPCH staff, or you, or anyone else likes it or not.

I believe that because she got angry Nurse Brennan grabbed my wrists, restraining me inappropriately, initiating a chain of events that eventuated in my torture.

Instead of stopping the chain reaction at any point along the way, Brennan kept it going, wanting to force me to speak. She chose to further punish me with seclusion and 5-point restraints. She did this for four and a half hours with deliberation and full knowledge of the possible consequences for me, consequences she checked off in boxes (“trauma to patient”) each time she had the doctor renew the order for restraints. I live with those consequences now and have had to live with them every day of my life since that night.

This is the truth of what happened, and I have told the truth on every occasion about this terrible incident at VPCH on the night of November 18, 2015, even when it was unpleasant and did not make me look good. I hope you will see that.

This was my complaint to the Adult Protective Services, as Licensing and Protection refused to investigate. I AM NAMING NAMES…OF THE GUILTY.

I had been mute for days prior to the date of Nov 18, 2015, when still mutein the early morning, on Unit D at Vermont Psychiatric Care Hospital I started slamming doors because I could not communicate my frustration at not being granted a PRN for Ativan. This was NEVER a danger to self or others. I had done this many times on the unit and was never punished for it, or restrained for it. I also had on file on the unit at that time a signed notarized Advanced Directive on the first 2 pages of which is stated in bold letters the request NOT to use ultimatums or seclusion or restraints because of previous traumatic experiences.

Annette Brennan, the charge nurse, apparently angry with me, came into my room and yelled: “I will not have you slam doors again on my watch!” She then backed me into my tiny bathroom, which I had been using as my bedroom ever since I had been admitted, and grabbed my wrists even though I was mute and unable to object, and when I attempted to biteher fingers to get freeshe called for me to be placed in seclusion.

Once in seclusion, she had staff reenter the seclusion room to have my wristwatch and glasses forcibly taken from me, resulting in injuries to my face and breaking my glasses, even though I was not demonstrating any violence or injurious behaviors, *not* until she called for a team and show of force to gang up on me.

Then she placed me in 5-point restraints only after she had staff reenter the seclusion room and I attempted to leave the seclusion room(if you look carefully at my chart you will see this was the reason for her calling for 5 point restraints and not violence of any sort) despite the Advanced Directive that had been much discussed during my stay in the prior three weeks. This AD states in unequivocal terms that seclusion and use of mechanical restraints has been extremely traumatizing for me and worsens my condition.

Not only that, Nurse Brennan convinced the on call doctor that my lack of speech was volitional and willful and wrote an order which she had Dr. Joseph Lasek sign that I was not to be removed from restraints *until I spoke aloud* NO MATTER HOW COMPLIANT I was, no matter how quietly I lay there. In point of fact they refused to ask me the requisite questions to let me out of restraints even though I lay so still I triggered an assessment every fifteen minutes… This order resulted in severe trauma and several hours of restraints. PLEASE NOTE that no one disputes the fact that I was mute and had been mute for days before this night. This order and Nurse Brennan’s part in what happened was torture. It constituted punishment and unnecessary restraint. None of it was necessary but Ms Brennan was angry with me for an episode of swearing that had occurred several weeks earlier and she lost her temper and her cool.

Brennan’s violated CMS regulations from the earliest point of this interaction because I was not a danger to myself or anyone else when Ms. Brennan first put hands on me, and only when I was touched against my wishes involuntarilythereafter could my behavior possibly been considered dangerous, and yet I was involuntarily restrained for several hours. Even a year later I still suffer an unbearable trauma from this event which my AD, a legal document, was intended to avoid, but it was ignored entirely…

THE FOLLOWING IS THE APS REPORT, WITH NEGATIVE FOR ABUSE…

1. On 11/22/15 DLP received a report indicating PW, alleged victim, was physically abused and unlawfully restrained by a staff member “Annette” at the Vermont Psychiatric Hospital. (Later identified as Annette Brennan, RN)

2. On 11/25/15 this investigator emailed PW to discuss the current allegations and arrange for a face to face interview with another investigator.

3. On December 3, 2015 Investigator Denise Anderson interviewed the alleged victim, PW, at Meadow View Recovery Residence in Brattleboro. PW has been residing at the facility since her discharge from Vermont Psychiatric Care Hospital. PW alleges staff at VPCH conducted an unlawful restraint on her during her stay at the hospital; she has documented this incident on her blog which she indicates she will provide to Investigator Holland-Kelley via e-mail. She stated the incident occurred around 1:00AM on November 18th, the day after her birthday. PW reported she had been “mute” for a few days and asked for a pill of Ativan as it helps her to speak. She stated the staff gave her .5mg and she stated she wanted another.5mg and they refused to give this to her. She stated she was agitated by this denial and a staff member named, Annette, entered the bathroom and grabbed her wrists and had PW’s arms over her head. PW stated she attempted to bite Annette. She stated at that point multiple staff persons entered the bathroom and escorted her out of the bathroom horizontally; each staff person having a limb, and “dumped her onto the mattress in the seclusion room.” PW stated she heard the staff persons conferring because PW had her eye glasses and other items on her person. She stated the staff entered the seclusion room and grabbed these items, including her eye glasses. PW stated this is when they injured her nose (PW has provided a photograph of these injuries). She stated when the staff attempted to exit the room she exited the room with them and the staff escorted her back into the room. PW stated the staff had told her she was not to exit the room but she ignored this command. PW stated it was at this point they used the restraints and secured her to the mattress. PW stated she was restrained for approximately 6 hours; she stated the staff are supposed to assist individuals with range of motion; PW stated she was fearful of developing a blood clot given she was restrained for so long. She stated she did range of motion to her body the best she could as a result. PW stated the staff interpreted this as resistance and considered her to be “flailing.” She stated she did not want to be humiliated by asking to go to the bathroom and then getting restrained again so she stated she opted to urinate in her clothing. She stated Annette “just wanted to take control of things; she wanted to be in control.” She stated she finally agreed to a safety plan and was released from the restraint.” PW does not believe the seclusion was necessary; she believes staff was unnecessarily rough in removing her glasses. PW believes the staff; specifically Annette just wanted to be in control. (Interview with PW,

4. PW meets the criteria of a vulnerable adult as she is over the age of 18 and she has chronic mental health conditions which require she receive assistance with her IADL’s and ADL’s. At the time of this report PW was an inpatient at a licensed psychiatric hospital in Vermont.

5. A review of medical records was done stemming from the noted incident on 11/22/15 involving PW and Annette Brennan, RN. According to the documentation, PW was behaving in an unsafe manner and was considered a danger to herself and others. The staff at VPCH followed hospital policy and procedures to ensure PW’s safety and the safety of the staff. PW was not cooperative with the on duty staff during this time and refused to communicate with them. To ensure everyone’s safety, the staff followed MD orders to assure PW was safe.

6. Further review of the incident report by Annette Brennan RN and other staff members dictate all staff was trying to work to keep PW safe as well as themselves. PW was attempting to kick and bite staff so they had to resort to means to keep everyone safe. Everything done was under the direction and orders of a physician.

7. On 12/21/2015 Mr. Perry stated the VPCH conducted their own investigation involving PW through the JCAH and he would send along the documentation requested for this investigation.

8. On 1/4/16 an invitation to interview letter/request was sent to witness Jennifer Mausukhan, RN with a response due 1/11/16. 9. On 1/4/16 an letter with an invitation to interview response was sent to Annette Brennan with a response date of Jan 15th

10. On 1/7/2016 Ms. Brennan had a telephone interview with this investigator. Ms. Brennan recalls being the nurse in charge on the particular day of the report. She recalls being in the back room with the supervisor and hearing banging going on outside the room. She went out to check and found PW had gone into her bathroom where she had put her mattress on the shower floor thus making her bathroom her safe room. She was trying to slam her door all the while she had 2:1 observation. There were 2 male staff members there. Ms. Brennan decided to put herself between PW and the 2 male staff members because she did not want the staff to be wrongfully accused of anything inappropriate with PW. PW hit Ms. Brennan in the stomach with a notebook and then went to swing at her with her other free arm. It was at this time Ms. Brennan made the decision to ‘take down’ PW and brought her out into the hallway. She had PW carried by 3-4 staff members to the seclusion area. The MD came to assess PW. PW was later searched and as the MD was leaving the room PW tried to attack him. PW grabbed one of the techs around the ankles and Ms. Brennan made the call to put PW in restraints at this time for her own safety and the safety of the staff. PW had received Ativan 1 mg. PRN but the MD did not want her to have any more Ativan. Ms. Brennan said she was checking PW from outside the room. She observed PW move all of her extremities as well as do some ROM (range of motion) to her feet and ankles. She went to check PW up close and PW kicked her in the groin. “I made the decision not to take her out of restraints for ROM”. An employee event was filed. PW screamed extremely loudly later on while still in seclusion. “I was the object of her anger as I was the one making the decision to put her in restraints. She did not just hit me she also hit other staff members and spit on them too. PW was taken out of restraints between 7 and 730pm that evening”. Ms. Brennan denies harming PW at any time.

11. On 1/7/2016 Ms. Mansukhani had a telephone interview with this writer. She stated she was on duty the day of the particular incident noted in this intake report. She stated it was the first time she had met with PW – she didn’t really know her well. She remembered PW going up to the window requesting more Ativan and being told she couldn’t have more (after checking with the MD). Ms. Mansukhani offered her some Melatonin but PW refused that offer. PW became enraged when she inquired which MD had been called and learned it was the MD on call and not her primary MD. (Per policy). PW was lying on the mattress on the floor of the bathroom when nurse Mansukhani went back in to see her. PW was on a 2:1 protocol. PW threw a notebook she had at the wall, not directly at anyone. PW tried to bite Annette (Brennan) and she was kicking. There were a lot of staff members there in the room. They picked PW up and carried her to seclusion area. The MD said not to medicate PW at this time. Ms. Mansukhani stated she went to the other side of the unit at this time because there were only 2 female staff members on duty on the other side and another patient was having a difficult time. PW’s side had 6-7 staff members. When she returned she said she saw PW had restraints on and remembered being surprised and asking what had happened. She recalls asking Nurse Brennan if anyone had checked the restraints on PW. Nurse Brennan told me she had been checking them when PW began kicking her and kicked her in the groin. We offered PW a bedpan which she refused. Ms. Mansukhani got the impression PW was cold and offered her a blanket but PW tried to ‘bite me’ so we removed the blanket. The team decided it was a safety issue so PW did not get the blanket. PW refused to speak to any of us (staff). Nurse Brennan and the doctor said PW had to ‘speak’ a contract to be taken out of restraints which she refused to do. PW later also refused to ‘write a contract with us’. At no time did Ms. Mansukhani observe PW being physically mistreated by any staff members. She observed PW being agitated and struggling with staff. She also observed PW hitting, spitting and kicking staff. “We all tried very hard to meet her needs and get her out of restraints. It didn’t work out that way,” Ms. Mansukhani stated.

Conclusion Statement: Based on the interviews conducted and the evidence reviewed this case will be unsubstantiated. The available evidence indicates A/N/E did not occur. PW was in the midst of a psychotic episode and unable to control her own actions. The mental health staff followed their designated policies and protocols to ensure everyone’s safety at that time.

PLEASE NOTE HOW THEIR STORIES DIFFER FROM EACH OTHERS, AND HOW MINE DIFFERS FROM THEIRS…

“In India when we meet and part we Often say, ‘Namaste’, which means: I honor the place in you where the entire universe resides; I honor the place in you of love, of light, of truth, of peace. I honor the place within you where if you are in that place in you and I am in that place in me, there is only one of us." ~~Ram Dass~~

“In India when we meet and part we Often say, ‘Namaste’, which means: I honor the place in you where the entire universe resides; I honor the place in you of love, of light, of truth, of peace. I honor the place within you where if you are in that place in you and I am in that place in me, there is only one of us." ~~Ram Dass~~